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Skeletal and dentoalveolar effects of mandibular advancement with clear aligners in the treatment of skeletal class II: A systematic review and meta-analysis
, Mohammed Faouzi Azaroual3, Fatima Zaoui3, Asmae Bahoum3
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Received: ,
Accepted: ,
How to cite this article: Tabchi Y, Bennani Mechita N, Elhilali S, Azaroual M, Zaoui F, Bahoum A. Skeletal and dentoalveolar effects of mandibular advancement with clear aligners in the treatment of skeletal class II: A systematic review and meta-analysis. APOS Trends Orthod. doi: 10.25259/APOS_123_2025
Abstract
This study aims to assess the skeletal and dentoalveolar effects of clear aligners in treating skeletal class II malocclusion and compare these effects to those achieved by conventional functional appliances in growing patients. A systematic electronic search was conducted in PubMed, the Cochrane Library, Scopus, Science Direct, and EBSCO HOST databases. The search was based on a defined research question following the Population, Intervention, Comparison, and Outcome principle. Risk of bias was assessed using the Newcastle-Ottawa Scale, and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation. Random-effects meta-analysis with subgroup analyses by control group type (untreated, Twin-Block, Herbst) were performed. Eight studies met the inclusion criteria, of which six were included in the meta-analysis. When pooling all control groups, no statistically significant differences were found between clear aligners and conventional appliances. However, subgroup analysis revealed that when comparing untreated controls to clear aligner’s significant reduction in A point-Nasion-B angle and an increase in Sella-Nasion-B angle were found. When compared to conventional appliances, clear aligners showed superior lower incisor control compared to Herbst appliances and greater upper molar extrusion. Clear aligners for mandibular advancement produce skeletal effects that exceed natural growth and are comparable to conventional appliances in growing patients. They offer potential advantages in lower incisor control but show a tendency for upper molar extrusion.
Keywords
Malocclusion angle class II
Mandibular advancement
Meta-analysis
Orthodontic appliances removable
Systematic review
INTRODUCTION
Skeletal class II malocclusion, often caused by mandibular retrognathia, is commonly treated in growing patients using traditional functional appliances such as the Twin-Block and Herbst appliances to stimulate mandibular growth and enhance condylar development. Recent advances in technology have led to the development of transparent functional appliances, such as clear aligners (e.g., Invisalign® MA, A6…), which combine the benefits of mandibular advancement with esthetic appeal and other advantages such as simultaneous teeth alignment and digital outcome visualization.[1]
While clear aligners present distinct advantages, debate remains regarding whether they can produce skeletal and dentoalveolar effects comparable to those achieved with traditional functional appliances. Recent studies have shown conflicting results, with some authors questioning their comparative skeletal effectiveness[2], whereas others have demonstrated comparable skeletal changes to conventional appliances.[3,4] However, variability in study designs, sample sizes, and outcome assessment methods across the literature limits the strength of the available evidence. Moreover, until now, no standardized protocols exist for evaluating the effects of mandibular advancement using clear aligners.
In contrast, functional appliances have been used for decades and are distinguished for their efficiency and favorable clinical outcomes. A systematic review by Cozza et al. identified the Herbst and Twin-Block appliances as the most efficient devices for mandibular advancement, reporting significant cephalometric changes and skeletal improvements.[1,5,6]
To date, no English-language systematic review has assessed the skeletal and dentoalveolar effects of mandibular advancement with clear aligners for treating skeletal class II malocclusion and specifically examined subgroup differences according to the type of control group.
Clinically, in an era focused on esthetics, clear aligners could offer a more patient-friendly alternative for growing patients with class II malocclusion. This paper aims to assess the skeletal and dentoalveolar effects of clear aligners in treating skeletal class II malocclusion and compare these effects to those achieved by conventional functional appliances in growing patients.
MATERIAL AND METHODS
Registration of protocol
This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines and was registered with PROSPERO (Registration # CRD42023445079). The PRISMA checklist is available in Supplementary File 1.[7]
Search strategy
We performed an electronic search across the following databases, focusing on studies published between 2013 and 2024:
PUBMED (MEDLINE)
The Cochrane library,
Scopus,
Science direct,
And EBSCO host databases.
Search strategies were developed for MEDLINE through PubMed. MesH terms and keywords were combined using Boolean operators and used to search the databases:
(advancement, mandibular[MeSH Terms]) AND (appliance, removable orthodontic[MeSH Terms])
((advancement, mandibular[MeSH Terms]) OR (interceptive orthodontics[MeSH Terms])) AND (appliance, removable orthodontic[MeSH Terms]),
((advancement, mandibular[MeSH Terms])) AND (appliance, removable orthodontic[MeSH Terms]))) AND (appliance, functional orthodontic[MeSH Terms])
The search was based on a defined research question following the Population, Intervention, Comparison, and Outcome principle, as shown in [Table 1].
| Population | Growing patients aged 9–16 years (CMV2, 3 or 4) diagnosed with a skeletal class II malocclusion with an ANB angle >4° and an overjet of 5mm or more |
| Intervention | Treatment with clear aligners utilizing the mandibular advancement method |
| Comparator | Mandibular advancement treatment involving the use of functional appliances for comparison |
| Outcome | - Evaluate and quantify the effects of mandibular advancement with clear aligners in skeletal class II patients - Compare the result of mandibular advancement using clear aligners with those obtained using traditional functional appliances in the patient group |
| Study design | Inclusion of retrospective, prospective as well as randomized and non-randomized clinical trials |
PICOS: Population, intervention, comparison, outcome, ANB: A point-Nasion-B, CMV: Cervical vertebral maturation
Inclusion and exclusion criteria
The inclusion and exclusion criteria are shown in [Table 2].
| Inclusion criteria | Exclusion criteria |
|---|---|
| - Studies involving mandibular advancement with clear aligners - Studies comparing clear aligners with traditional functional appliances for mandibular advancement - Studies using either conventional or three-dimensional imaging modalities to assess the results obtained |
- Full text not available - Not published in English - Any study that included patients with cleft lip and palate or any congenital diseases in their sample - Studies that lack cephalometric or study model data to measure outcomes |
Data extraction method
Two authors independently assessed all titles and abstracts for eligibility. If exclusion criteria were met, the study was rejected. In cases where the protocol or appliance type was unclear, the full text was retrieved for evaluation.
Then, a narrative synthesis was performed, and data extraction was conducted using a predefined extraction sheet [Table 3].
| Author, year of publication and country | Study design | Intervention | Type of control | Sample size | Age | Evaluation method |
|---|---|---|---|---|---|---|
| Caruso et al. (2021) Italy[10] | Retrospective cohort clinical trial | Invisalign mandibular advancement | Twin block appliance | 20 | Mean age: 10±1.03 | Lateral cephalometric radiographs |
| Ravera et al. (2021) Italy[11] | Prospective cohort clinical trial | Invisalign mandibular advancement | Untreated control group | 40 | - CVM2: Average age 9 years 2 months - CVM3: Average age 12 years and 10 months | Lateral cephalometric radiographs |
| Sun et al. (2022) China[12] | Retrospective comparative cohort clinical trial | A6 appliance for mandibular advancement | Twin block | 46 | Mean age: 13.66±4.25 years | Lateral cephalometric radiographs |
| Sabouni et al. (2022) Egypt[13] | Retrospective cohort study | Invisalign mandibular advancement | No control | 32 | Average: 13 years old | Cephalometric analysis and statistical evaluation |
| Lombardo et al. (2023) Italy[14] | Retrospective comparative cohort clinical trial | Invisalign mandibular advancement | Twin block untreated control group | 56 | TB group: mean age 12.0±1.3 years (CS3) MA group: mean age 11.2±1.1 years (CS3) | Cephalometric analysis and comparison with controls |
| Wu et al. (2023) China[3] | Retrospective comparative cohort clinical trial | Invisalign mandibular advancement | Twin block, Herbst appliance, Vanbeek activator, Untreated control group | 63 | Cervical vertebral maturation VM2 | Cephalometry and Johnston’s Pitchfork analysis |
| Kong and Liu (2023) China[15] | Retrospective cohort study | Invisalign mandibular advancement | No control | 30 | Cervical vertebral maturation stage between CVMS1 and CVMS3 | Pancherz analysis and cephalometry |
| Hosseini et al. (2024) Canada[4] | Retrospective cohort clinical trial | Invisalign mandibular advancement | Herbst appliance | 30 | 13.1 years (±1.5 years) for the Invisalign Mandibular Advancement group 12.7 years (±1.8 years) for the Herbst group | Cephalometric analysis |
CVM: Cervical vertebral maturation, MA: Mandibular advancement device, TB: Twin-Block appliance
Skeletal changes were assessed using Sella-Nasion-B (SNB), A point-Nasion-B (ANB), and Frankfort Mandibular (FMA) angles, while dentoalveolar changes focused on overjet, lower incisor inclination, incisor mandibular plane angle, and maxillary molar position. Any disagreements were resolved through discussion with two seniors until a consensus was reached.
Quality and risk of bias assessment
Two authors independently evaluated and assessed the risk of bias in each study using the Newcastle-Ottawa Scale (NOS) tool.
The NOS tool uses a star system to evaluate study quality. Studies scoring seven to nine stars were classified as low risk of bias, five to six stars as medium risk, and studies with less than five stars as high risk of bias. The star allocation reflected study quality across three domains: Selection of study groups (4 stars maximum), comparability of groups (2 stars maximum), and ascertainment of exposure/outcome (3 stars maximum).[8]
In case of any disagreements regarding the risk of bias, a third senior reviewer was consulted.
Certainty of the evidence
The grading of recommendations assessment, development, and evaluation (GRADE) approach was used to judge the quality of the evidence obtained, using GRADEpro software. Each outcome could obtain a high, moderate, low, or very low evidence value depending on the study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias.[9]
Data synthesis
Statistical analyses and data synthesis were conducted by two authors using the RStudio platform. A random-effects model was chosen to pool standardized mean differences with 95% confidence intervals (CI). Heterogeneity was assessed using I2 and tau2, and subgroup analyses were performed to compare the results obtained based on the treatment type: Untreated control group patients, Twin Block control group patients, and Herbst control group patients. Forest plots were generated to visualize the individual and pooled estimates.
RESULTS
Study selection
Our search of five databases yielded a total of 739 records. After de-duplication using a referencing manager software, namely, Zotero, 480 studies remained. On reviewing the title and the abstract, 227 studies were discarded for not fulfilling our inclusion criteria. Two authors independently assessed the full text of 32 studies for eligibility, of which 24 were excluded. The summary of study selection is presented within the flow chart following the PRISMA 2020 flow diagram [Figure 1].
Study characteristics
The primary characteristics of the individual studies are summarized in [Table 3]. Eight studies met our inclusion criteria and were included in our systematic review. Among these, seven were retrospective[3,4,10-15] and one was prospective.[11]
Five studies compared the skeletal and dentoalveolar changes between clear aligners for mandibular advancement and other functional appliances.[3,4,10,12,14] Three studies included untreated patients as their control group to evaluate the effects of clear aligners for mandibular advancement.[3,11,14]Two cohort studies evaluated mandibular advancement with clear aligners without a control group.[10,15] The largest sample included 63 patients, while the smallest included 20 patients.[10]
Moreover, all included studies assessed skeletal and dentoalveolar changes using lateral cephalograms taken before treatment and at the end of the mandibular advancement phase.
Risk of bias within studies
[Table 4] shows the risk of bias assessment for cohort studies included in our review.
 |
The risk of bias assessment using the NOS revealed that three studies demonstrated a low risk of bias (scores of 8/9),[4,10,11] while five studies showed a medium risk of bias (scores of 6/9).[3,12-15]
The primary reasons for downgrading studies from low-to-moderate risk were as follows:
Insufficient details regarding control patient selection in several studies,[3]
Absence of an untreated control group in some studies makes it harder to differentiate between the actual effects of the treatment and natural differences in patient growth.[12-15]
We recognize that the combination of retrospective and prospective studies may introduce methodological heterogeneity. This difference was carefully considered during our analysis.
Certainty of evidence
The certainty of evidence for the included studies ranged from low to very low according to GRADE criteria due to:
Risk of bias: Several studies showed methodological concerns, including insufficient details on patient selection processes, incomplete follow-up reporting and short-term evaluation, and absence of an untreated control group in some studies.[3,12-15]
Inconsistency: Substantial heterogeneity between studies with I2 values ranging from 52% to 78% for most outcome parameters [Figures 2-4].
Imprecision: Wide CIs with the possibility of no effect, primarily due to small sample sizes (ranging from 20 to 63 patients per study).
Indirectness: Variations in clear aligner systems (Invisalign MA vs. A6), mandibular advancement protocols, and outcome measurement methods across studies.
A summary of findings table was produced to present outcomes and overall certainty of evidence according to GRADE criteria. The results are shown in [Figure 5].
Meta-analysis (quantitative summary)
Two studies were excluded from the meta-analysis as they lacked a control group, reporting only pre- and post-treatment measurements without comparison.[13,15]
Six studies were included in the meta-analysis comparing clear aligners to conventional functional appliances and/or untreated controls. For overall pooled analysis, no statistically significant differences were found between clear aligners and controls for ANB, SNB, FMA, IMPA, and overjet (P > 0.05 for all comparisons). However, a statistically significant difference was observed for U6-PP (MD = 0.92 mm, 95% CI [0.08; 1.75], P = 0.03), indicating greater upper molar extrusion in the clear aligner group.[3,4,10-14]
Given the heterogeneity observed, subgroup analyses were performed based on control group type (untreated patients, Twin-Block or Herbst appliances). The analyses revealed important findings [Figure 5].
ANB angle: When comparing clear aligners to untreated control patients, a significant reduction in ANB angle was observed in the clear aligner group (MD = −1.08, 95% CI [−1.40; −0.76]), indicating effective skeletal class II correction beyond natural growth. However, when comparing clear aligners to Twin Block or Herbst appliances, no statistically significant differences were found, suggesting comparable skeletal correction.
SNB angle: Clear aligners showed a statistically significant increase in SNB angle compared to untreated controls (MD = 0.54; 95% CI [0.06; 1.01], P = 0.03), reflecting forward mandibular positioning beyond natural growth. No significant differences were observed when comparing clear aligners to Twin-Block or Herbst appliances, suggesting similar mandibular advancement effects.
IMPA angle: A statistically significant difference was found when comparing clear aligners to Herbst appliances (MD = −7.63; 95% CI [−10.79; −4.48], P < 0.001). This negative mean difference result indicates that the mandibular incisors were significantly more proclined in the Herbst group compared with the clear aligner group. No significant differences were observed compared to untreated controls or Twin Block appliances (P > 0.05)
U6-PP measurement: Clear aligners showed statistically significant upper molar extrusion compared to Herbst appliances (MD = 1.52; 95% CI [0.05; 2.99], P = 0.04). No significant differences were found when comparing clear aligners to untreated patients.
Moreover, all measurements showed moderate-to-high heterogeneity with I2 values ranging from 52% to 78%, indicating a significant variability between studies, which reduces confidence in the pooled estimates and necessitates cautious interpretation of results [Figure 3-5].
DISCUSSION
The primary aim of this paper was to assess the skeletal and dentoalveolar effects of mandibular advancement using clear aligners in growing patients. The qualitative synthesis from our systematic review showed that clear aligners promote clinically mandibular growth and improve sagittal skeletal and dentoalveolar relationships. In addition, the subgroup analysis from our meta-analysis further supported the efficacy of clear aligners in treating skeletal class II malocclusion.
The comparison of clear aligners to untreated control groups provides insight of treatment effects versus natural growth changes. Our subgroup analysis revealed statistically significant differences: A reduction in ANB angle (MD = −1.08°, 95% CI [−1.40; −0.76]) and a greater increase in SNB angle (MD = 0.54°, 95% CI [0.06; 1.01]). These findings confirm that clear aligners produce skeletal changes to correct skeletal class II that exceed natural growth.[3,4,10-15]
Secondarily, when comparing the clear aligners to conventional appliances (Twin-Block and Herbst), the quantitative analysis from our meta-analysis exhibited no statistically significance differences for key skeletal parameters, including ANB, SNB, and FMA. This finding implies that clear aligner produces skeletal effects comparable to well-established traditional functional appliances.[2,3]
This comparable skeletal efficacy suggests that clear aligners can achieve treatment outcomes similar to traditional approaches. Similarly, no statistically significant difference was observed for overjet correction between the treatment modalities.
For dentoalveolar variables, U6-PP showed a statistically significant overall effect, indicating that clear aligners may induce an increase in the alveolar bone height of maxillary posterior teeth, reflecting an extrusion of the upper first molars during mandibular advancement. The mean extrusion reached 0.92 mm. Our subgroup analysis for U6-PP showed that this effect was particularly marked in the Herbst subgroup (MD = 1.52 mm, 95% CI [0.05; 2.99]). Similarly, Sun et al. reported the same finding, explained by the combined effect of growth and the occlusal role of the posterior teeth during mandibular advancement.[12]
Interestingly, most existing literature reports a tendency for posterior molar intrusion with clear aligners, particularly during planned movement such as molar distalization in adult patients.[16,17] However, in the context of mandibular advancement treatment for growing patients, our result suggests the opposite. This divergence could be explained by limited vertical tooth control of clear aligners in the posterior region during mandibular advancement mechanics, the ongoing craniofacial growth contributing to vertical alveolar development, or the posterior occlusal opening inherent mandibular advancement mechanics.
In our meta-analysis, clear aligners showed a statistically significant difference in the IMPA angle compared to Herbst appliances, with a mean difference of −7.83° (95% CI [−10.79; −4.48]). This finding indicates that Herbst appliances induce significantly greater labial tipping of mandibular incisors than clear aligner treatment, a well-documented side effect of this functional appliance.[18,19] This dental compensation resulted from the continuous forces applied to the lower incisors through the appliance mechanism. Thus, clear aligners provide better control over the lower incisor inclination, maintaining favorable IMPA values throughout treatment. This advantage could be attributed to the sequential tooth movements programmed into aligner. This observation aligns with the results of Wu et al.’s study.[3]
The substantial heterogeneity observed across the included studies (I2 values ranging from 52% to 78% for most parameters) significantly limits the generalizability of our pooled estimates and necessitates cautious interpretation. This heterogeneity can be attributed to:
Treatment protocol variations: The included studies utilized different aligner systems (MA versus A6) with varying mandibular advancement protocols.
Patient age heterogeneity: The mean age varied considerably across studies (ranging from 9.0 to 13.66 years). In addition, some studies used cervical vertebral maturation stages to assess skeletal age. This variability indicates that patients were treated at different stages of maturation and growth potential relative to the growth peak, which could have influenced the results.
Measurement methodology: Variations in landmark identification protocols in lateral cephalometric radiographs, measurement techniques, and operator experience contributed to outcome variability.
Control group diversity: Studies employed different control groups (untreated, Herbst, Twin Block), this diversity complicates direct comparisons.
One major clinical consideration is that the success of clear aligner therapy is largely dependent on patient compliance in wearing correctly and consistently the aligners. Without strict adherence to the prescribed wear schedule, the potential of clear aligners to achieve the desired skeletal and dentoalveolar results is limited. This factor should be evaluated when selecting patients for clear aligner’s mandibular advancement treatment.
Limitations
This systematic review and meta-analysis highlights several limitations in the existing literature:
The included studies were mainly retrospective cohort. Retrospective design does not automatically imply bias; however, several studies showed methodological concerns.
The GRADE assessment indicated that the certainty of the evidence ranged from low to very low, reinforcing the need for cautious interpretation.
The substantial heterogeneity observed across studies was ranging from moderate-to-high for most parameters. This high variability in treatment protocol, patient age, and treatment outcome limits the ability to draw definitive conclusions and reduces the robustness of the findings.
The small sample sizes within the included studies further reduced statistical power and the confidence in the pooled estimates.
Short-term follow-up: Most studies evaluated short-term outcomes (6–18months), with limited information on long-term stability.
Given these limitations, future prospective research and randomized controlled trials with larger sample sizes and standardized methodologies are necessary to confirm the efficacy of clear aligners in the treatment of skeletal class II malocclusion in growing patients.
CONCLUSION
Clear aligners showed a statistically significant skeletal improvement when compared to untreated controls, with a reduction in ANB angle and increase in SNB angle, confirming their effectiveness in treating skeletal class II malocclusion in growing patients beyond natural growth. When compared to conventional appliances (Twin-Block and Herbst), clear aligners showed no statistically significant differences in key skeletal parameters (ANB, SNB, and FMA) or overjet correction, indicating similar skeletal effects.
For dentoalveolar effects, clear aligners showed a statistically significant increase in U6-PP, indicating a tendency for upper molar extrusion during mandibular advancement with clear aligners. Moreover, clear aligners exhibited a superior control of lower incisor inclination compared to Herbst appliances during mandibular advancement.
However, the clinical applicability of these conclusions is limited by methodological restraints. The overall low to very low certainty of evidence, the substantial heterogeneity, and the lack of standardized treatment protocols limits the robustness of our conclusions.
Current evidence supports the use of clear aligners as a viable treatment option for skeletal class II malocclusion in carefully selected growing patients, though additional high-quality research is necessary to strengthen the evidence.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent was not required as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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